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Persons with a spinal cord injury (SCI) are not usually required to stick to a specific diet, although a balanced diet that is adapted to the individual's needs is recommended. The energy needs in those with a spinal cord injury are significantly lower than those without a spinal cord injury. However, the need of vitamins and minerals stays the same. Beverages (Source: © fotolia) The recommended daily fluid intake in persons with SCI is normally 2-3 litres, which is slightly higher than in those without an SCI in order to prevent constipation and urinary tract infections. In case of a urinary tract infection, drinking an increased amount of fluids (e.g. diuretic tea) may be helpful. In order to prevent urinary tract infections, products containing cranberries may be helpful – though it is recommended to consult your physician beforehand. Unsweetened beverages: Mineral and tap water (e.g. with a slice of lemon or orange) as well as herbal, fruit, green and black teas are all optimal sources of fluid. Strongly diluted fruit and vegetable juices, zero-calories drinks and coffee also supply fluid, nevertheless they should be consumed consciously and in small amounts. Sweetened beverages: The high amount of glucose/sugar in these beverages provides a high level of energy, are empty calories, and do not contain vitamins or minerals. Consumption of these beverages can cause weight gain and tooth decay. Fruit/vegetable juices (e.g. orange or carrot juice), undiluted and unsweetened: 200 ml of undiluted fruit or vegetable juice can be used as a replacement for one portion of fruit or vegetables. It therefore falls under the category of food, not beverages. Milk: Due to the high amount of calories that it contains, milk also falls under the food category and is not to be considered a thirst quencher. Fruit and vegetables: Vitamins and fiber (Source: © fotolia) The recommended amount is five portions per day: two portions of fruit, preferably raw and of a variety of different colors, and three portions of vegetables. One portion equals about 120 grams or around one handful. Fruit and vegetables contain many different vitamins (e.g. vitamin C, beta carotene), minerals (e.g. magnesium, iron) and dietary fiber. In addition, every fruit/vegetable color contains other secondary plant substances (e.g. lycopene, flavonoids). These strengthen our immune system, have anti-inflammatory characteristics, regulate the blood pressure, decrease the cholesterol level and can help to prevent cancer. Fruit and vegetables should be eaten fresh – storing them too long in the refrigerator, cooking them for too long or keeping them warm reduces their vitamin content. Enjoying 3-4 pieces of dried fruit, 200 ml of fruit or vegetable juice or the consumption of frozen fruit and vegetables may help to reach five portions per day. Due to their high water content, fresh and unprocessed fruit and vegetables are low-energy foods. Raw, steamed or otherwise low-fat prepared vegetables are therefore especially valuable for persons with SCI and they can eat as much as they like without having to worry about gaining weight. Grains, potatoes and legumes: carbohydrates and proteins (Source: © fotolia) The recommended amount of carbs is around three portions per day. One portion equals 75-125 g of bread/dough or 60-100 g of legumes (dry weight) or 180-300 g of potatoes or 45-75 g of crispbread, whole grain crackers, granola, flour, pasta, rice, corn, oats, millet or other grains (dry weight). Whole grain products, legumes, other grain products and potatoes are rich in starch – hence they are also called starchy-sides. They contain vegetable protein, provide dietary fiber and B vitamins. Among plant-based foods, legumes contain the highest protein level, i.e. about 20 %. (Source: © fotolia) When consuming grain products, whole grain products are preferred since the grain shell and the germ bud contain most of the vitamins, minerals (magnesium, iron or zinc), proteins, secondary plant substances and dietary fiber. Whole grain products may be ground finely which makes them easier to chew and digest. Refined products (white flour) contain considerably fewer vitamins, minerals and dietary fiber. Therefore whole grain products are very important for persons with SCI in order to consume fewer calories whilst still getting the vitamins and minerals they need. Gluten intolerance (coeliac disease): Intolerance to gluten needs to be diagnosed by a specialty physician before adjusting the diet. Afterwards, in an appointment with a nutritionist, a gluten free diet is determined. Milk and dairy products: proteins and calcium (Source: © fotolia) The daily consumption of three dairy products is recommended. One portion equals 200 ml of milk or 150-200 g of yoghurt, quark or cottage cheese or 30 g of semi-hard or hard cheese 60 g of soft cheese Milk contains valuable milk protein as well as vitamins and minerals. Calcium and especially phosphorus are important for building and supporting the bones and in SCI persons, they contribute to the prevention of inactivity osteoporosis. When choosing dairy products, an important factor to consider is their fat content – many of them contain a very high level of fat. Low-fat products (e.g. cottage cheese, low-fat cream cheese, low-fat quark, skimmed milk, half and half cream, Ziger cheese, ricotta) are preferred to high-fat products (e.g. hard cheeses, cream, mascarpone). Lactose intolerance: There are many lactose-free dairy products and yoghurts available as an alternative. Hard, semi-hard cheeses and butter contain only traces of lactose or none at all. Meat, fish, eggs and tofu: proteins (Source: © fotolia) One portion of these products is recommended per day – preferably exchanging them on a daily basis. One portion equals: 100-120 g of meat, poultry, fish, tofu, quorn, seitan (fresh weight) or 2-3 eggs. These foods contain very high-quality proteins as well as vitamins (e.g. B12, A, D, K) and minerals. The iron in meat, fish and eggs can be absorbed especially well by our bodies. In order to minimize the consumption of fat and nitrite curing salt, low-fat meat are more suitable than meat and sausage products (e.g. salami, bologna, meat loaf, luncheon meats). Another way to reduce the intake of fat is by using a non-stick frying pan without using additional fat or preparing meat in the oven or in a soup. Fish provides iodine as well as valuable omega-3 fatty acids, which have a positive effect on the cardiovascular health also in persons with SCI. High-fat fish (e.g. salmon, herring, mackerel, sardines) contain more omega-3 fatty acids than low-fat fish (e.g. whitefish, bass, hake, cod, flounder). Eggs contain the best high-grade protein and the protein, fat, cholesterol and vitamin A content of the egg yolk is higher than the one of the egg white. Tofu and quorn contain dietary fiber whose iron, however, is not as effective in our bodies as the iron from meat. Important for vegetarians and vegans: Tofu und quorn do not contain any vitamin B12. It is recommended for vegetarians and vegans especially to discuss their diet with their nutritionist in order to prevent nutritional deficiencies. Fats, oils and nuts: fats (Source: © fotolia) It is recommended to eat a handful of unsalted and unroasted nuts, seeds or kernels and 2-3 tablespoons of vegetable oil per day. Additionally about 10 g (1 tablespoon) of spreadable fat can be eaten. Olive oil and canola oil are especially suitable for uncooked dishes. Oil, fat and nuts should be eaten on a daily basis since they contain vitamin E, essential fatty acids and secondary plant substances. Not recommended, however, is the consumption of larger amounts because fat contains the highest caloric value among the food groups (1 gram equals ca. 9 kcal – 1 gram of carbohydrates/proteins contains ca. 4 kcal). A moderate use of spreadable fats (butter, margarine) and using low-fat cooking methods (e.g. non-stick frying pan, steaming) is recommended. Fats, or fatty acids as components of fat, differ strongly in quality. Fatty acids can be saturated, mono- or poly-unsaturated. The poly-unsaturated fats are also called essential fatty acids since they are indispensable for numerous functions of the organism and the body itself cannot produce them. These essential fatty acids are, among others, omega-6 and omega-3 fatty acids. It is healthier to eat a higher portion of mono- and poly-unsaturated fats and to reduce the intake of saturated fatty acids (hydrogenated fats). This can be achieved by cooking only with small amounts of butter, margarine and cream, as well as only consuming moderate amounts of fatty meat, dairy products and pastries (e.g. puff pastry, short pastry, cookies). This is especially important for wheelchair users who are not very physically active because it can help them to prevent heart disease. Dietary fiber (Source: © fotolia) Dietary fiber is mainly the material of the cell membrane of edible plants. They belong to the carbohydrate family. Studies show that a sufficient supply of fiber is necessary for a normal digestion process. Fiber stimulates our chewing activity and therefore the production of saliva – the first step to a good digestion. Foods high in fiber stay in the stomach longer and therefore cause a longer-lasting feeling of satiety. For persons with SCI, fiber is helpful to stimulate bowel movement (intestinal peristalsis). Fiber can be split into two sub-categories: Insoluble food fiber: These absorb water in the intestines while soaking which increases the volume of the food pulp. The muscles of the intestinal walls are thus stretched and bowel movement is stimulated. The feces become softer and the time of passage of the food pulp through the intestines becomes shorter. Insoluble food fiber is contained in whole grain flour, whole grain rice, cabbage and nuts, for example. Soluble food fiber: These form a kind of a gel when coming into contact with water and are nutrients for both the intestinal bacteria and the villi. The villi are responsible for the absorption of nutrients. The supply of soluble food fiber furthermore increases the number of intestinal bacteria. They increase the amount of water in the intestines and the feces become heavier. This, again, increases the bowel movement and the time of passage of the food pulp becomes shorter. Soluble food fiber is contained in legumes, oats, carrots, apples and citrus fruit, for example. For additional information about the topic of nutrition, the website of the Swiss Society for Nutrition is recommended: http://www.sge-ssn.ch.   About the authors: Susanne Morach holds a Bachelor in Nutrition and Dietetics and for her master in Health Sciences (2013-2015) she also worked for the Swiss Paraplegics Association. Dr. med. Hans Georg Koch was head physician for 19 years at the Swiss Paraplegic Centre in Nottwil/Switzerland. Together with Guido A. Zäch, founder of the Centre, he published a book that has become a key textbook in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation". Hans Georg Koch is a member of the paraforum team. updated: May 2015
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Within the various rehabilitation and life phases of a person with spinal cord injury (SCI), it is important to avoid malnutrition and the complications that come with it. Since nutritional needs vary from person to person, and they may also change during the process of rehabilitation or due to complications, the supply of nutrients also needs to be customized individually. Nutritional counselors record the nutritional status and offer professional support for customizing the diet to your needs. Goal of a healthy diet is not only to cover the nutritional needs but also to develop a diet that can be integrated into everyday life and that coincides with the preferences and habits of a person. Quality of life and pleasure from food also play a significant role for your diet. Steps of a nutritional therapy Steps of a nutritional therapy Malnutrition Reasons Insufficient supply because of: lack of appetite difficulty in swallowing (dysphagia) mental stress Increased need through: health conditions metabolic changes in stress situations (e.g. caused through a health condition) Consequences Decreased well-being Decrease of muscles and therefore of strength Decreased immune defense, increased risk to become sick/get an infection Poor skin, risk to develop pressure sores, poor wound healing Difficulties with bowel management Also overweight persons might suffer from malnutrition, e.g. when they are lacking a specific nutrient (often proteins, minerals and vitamins). Nutritional counselors... calculate the individual need of calories and proteins help with the choice of suitable food give advice for creating a menu under consideration of individual needs explain how to consume a sufficient amount of specific nutrients may recommend suitable supplements if requested, include family members in the counseling process take care tube feeding may be required, order the products and get in contact with the health insurance for cost coverage in Switzerland Overweight Reasons Reduced exercise Decrease of muscles Decreased basal metabolic rate Mental factors such as loneliness, frustration, stress, etc. Consequences Decreased well-being Metabolic disorders such as diabetes mellitus type 2 or Lipometabolic disorders Increased difficulty in transferring and limitations in mobility pressure sores The nutritional counselors… measure the individual energy needs by conducting a breath test give advice when choosing suitable food may recommend a physio- or sports therapist if necessary if requested, include family members in the counseling process Problems with digestion Reasons Decreased bowel movement through spinal cord injury Decreased amount of exercise Possible intolerances Side effects from specific medication Spasticity and pain Mental, social and cultural aspects (e.g. when travelling) Consequences Flatulence Constipation Diarrhea Discomfort The nutritional counselors… show various factors that influence the bowel management avoid unnecessary restrictions that may lead to an unbalanced diet calculate the individual's need for fibers and liquid and make recommendations accordingly help with the choice of suitable foods if required, get information from the GP in order to get an idea of the whole picture Decubitus (pressure sores) Reasons Specific nutrients are missing (often proteins, zinc, vitamin D, vitamin C) Overweight/underweight Consequences Immobilization Pain Prolonged hospital stays Possible surgery The nutritional counselors… calculate the individual's need for calories, proteins and liquid and make recommendations accordingly supplement specific nutrients that are insufficiently contained in the blood offer specific supplements to improve wound healing FAQs Is there a specific diet for people with spinal cord injury? There is no specific diet. It is recommended to eat healthy and balanced foods to get a sufficient amount of all nutrients. It is recommended to eat fewer fibers compared to people without SCI. How does the body composition change? The amount of muscles is reduced through lack of activity. This involves a reduced basal metabolic rate and therefore also a decrease of energy consumption. What am I allowed to eat? You may eat whatever you like. Same as for people without SCI, the amount plays an essential role. Since the energy consumption decreases, it is important to consume high-energy foods (e.g. soft drinks, snacks, sweets) only in small amounts. Is it necessary to take nutritional supplements? If you are eating a balanced mix of foods, it is not necessary to take supplements. In specific situations, however, e.g. at an increased need during a health condition or if a shortage was determined in the blood, specific nutrients are being supplemented. How and where can I get nutritional counseling? Nutritional counseling can be prescribed by your GP. It is also possible to make an appointment for nutritional counseling at a clinic. About the author: Yvonne Häberli is head of the Department for Nutritional Counseling at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 2012. updated: December 2013
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Hippotherapy is a recognized treatment of physiotherapy that uses a small horse. During hippotherapy the rhythmical three-dimensional movements of the horse are transferred on the patient and can thus be used therapeutically without the patient actively influencing the horse. Even the transfer itself – mounting and dismounting the horse – forms an essential part of the treatment. Transfer from the horse into the wheelchair Mode of action The movements of the back of the horse have above all loosening but also strengthening and stimulating effects. The patient sits with his/her legs spread over the back of the horse which is being lead by a horse guide while the gait is walking. This sitting position alone can have a positive influence on the tight muscles of torso and legs. The therapist supports the patient and gives instructions for doing the exercises. Additionally the therapist can stimulate the desired pelvic movements of the patient. This results in a permanent tensing and relaxing of the muscles. Simultaneously balance, posture reactions of the torso and coordination are trained, weak muscles are being strengthened and tension is released. Hippotherapy can thus be used for various goals, often to decrease pain or to regulate muscle relaxation. In a study about increased muscle tonus (spasticity) in persons with spinal cord injury improvements were noted through hippotherapy (Lechner et al. 2003). Furthermore hippotherapy has a psychologically positive and motivating effect. During hippotherapy balance and coordination are trained. The therapist supports the patient while stimulating the desired pelvic movement at the same time. The individual characteristics and the nature of the horse are very important. Therapy horses are not necessarily a certain breed but are specifically trained and highly sensitive. During the training they learn to get used to wheelchairs and walking aids and to stand next to lifts or ramps and how to deal with the untypical movements of the patients. The goal of training the horse is to "simultaneously use all movement options while granting the highest safety factor during hippotherapy" (Deutsches Kuratorium für Therapeutisches Reiten e.V. (DKThR), translated). With the help of a trusted, people-friendly and obedient horse the behavior and condition of the patient can be influenced positively. What is required from the horse? Mental and emotional suitability for a focused reception and execution of commandos Muscle strength and stamina Ability to stand quietly and patiently beside a ramp Confidence in various therapy material (walking aids, wheelchairs, etc.) Ability to be lead on both sides at neck and shoulder levels Being insensitive toward spasticity and imbalance of the patient Staying calm while surrounded by several people Ability to stay calm despite any kind of environmental impacts or noises Cost coverage and prescription After finishing the acute phase, hippotherapy can be applied in hospitalized patients as well as during outpatient care. It is usually applied in patients with neurological conditions, e.g. in case of spinal cord injury or stroke. The costs for hippotherapy are partially covered by the health insurance companies or are paid by the disability insurance, in Switzerland for example adults with multiple sclerosis or children with cerebral palsy. For other conditions the financing options need to be investigated by a third party. In Switzerland the therapy, like any kind of physiotherapy, needs to be prescribed by a physician and can be applied only by a physiotherapist with additional training in hippotherapy. This is usually an advanced training according to Künzle (Hippotherapy-K). In Switzerland only therapeutic treatment by a professional with this specific training is billable to the health insurance. Hospitalized patients with spinal cord injury are covered by the daily hospital allowance. The therapy team consists of patient, a trained therapy horse, a hippotherapist (physiotherapists with advanced training in Hippotherapy-K) and a horse guide. Hippotherapy is usually done once a week. It can take place outside or inside. The treatment length depends on the strength and performance of the patient and is 30 minutes on average. The patient is supported by the therapist the whole time. It is not obligatory to wear a helmet (DKThR). What is required from the patient? The person needs to be able to sit fairly stable and has a certain amount of control over his/her torso and is able to move the head without support. Whether a patient is able to participate in hippotherapy or not has to be determined by trained staff. The minimum age for children is four years. Hippotherapy takes place outdoors. Further information online (in German and French): Schweizer Gruppe Therapeutisches Reiten: http://sg-tr.ch/v2/verein/ Österreichisches Kuratorium für Therapeutisches Reiten: http://www.oktr.at/ Deutsche Gruppe für Hippotherapie e. V.: http://www.dgh-ev.com/startseite.html Schweizer Gruppe für Hippotherapie-K®: http://www.hippotherapie-k.org/index.php?id=27 Association Suisse de Thérapie Avec le Cheval: http://www.therapiecheval.ch/ Institut de Formation en Equithérapie: http://www.ifequitherapie.fr/ Pferdegestützte Therapie Schweiz / PT-CH: http://www.sv-hpr.ch/de/Home ESAAT - European Society for Animal Assisted Therapy: http://www.esaat.org/; together with the international organization ISAAT it developed guidelines for the quality assurance of animal-supported interventions in the health system References: Schweizer Paraplegiker-Zentrum: Hippotherapie, Heilpädagogisches und Therapeutisches Reiten. URL: http://www.paraplegiker-zentrum.ch/de/pub/spz/bereiche/physiotherapie/hippotherapie.htm (retrieved July 30, 2015) Lechner HE, Feldhaus S, Gudmundsen L, Hegemann D, Michel D, Zäch GA, Knecht H. The short-term effect of hippotherapy on spasticity in patients with spinal cord injury. Spinal Cord. 2003 Sep;41(9):502-5. Deutsches Kuratorium für Therapeutisches Reiten e.V. (DKThR): Wie wird Hippotherapie durchgeführt? URL: https://www.dkthr.de/de/therapeutisches-reiten/hippotherapie/wie-wird-hippotherapie-durchgefuehrt/ (retrieved July 30, 2015) Abramovic M et al.: Hippotherapie. In: Zäch GA, Koch HG (Hrsg.) (2006): Paraplegie. Ganzheitliche Rehabilitation. Basel: Karger, S. 355f. About the authors: The article was written by the Team of Experts for Hippotherapy, Curative and Therapeutic Horseback Riding at the Department of Physiotherapy of Swiss Paraplegic Center (SPZ) in Nottwil, Switzerland, above all Sabine Grupp, Kathrin Kriesche and Sibille Bühlmann. Dr. Andrea Glässel is a physiotherapist and researcher at Swiss Paraplegic Research (SPF) in Nottwil, Switzerland where she has been working since 2007. She is a member of the paraforum team. updated: October 2015
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Awareness of the body, regulating effects on spasticity, free and deeper breathing, feeling well and an increased fitness: These are only a few aspects of the feedback with regard to positive effects that yoga can have for people with spinal cord injury (SCI). Enough reasons for us, to have a closer look at this ancient tradition. Originally, yoga is an Indian (also Tibetan) philosophical tradition and means “connect" or “unite". This signifies the connection between our individual human awareness and an infinite awareness as well as between body, spirit and soul. In the occidental philosophy, knowledge is acquired often through scientific studies; in the Indian tradition, however, one experiences reality through direct and personal experiences. The goal in doing yoga is to find out more about our inner values, to learn more about truth and our true identity or to experience our higher self. Yoga in its traditional form is a comprehensive system that deals not only with physical exercises, breathing techniques, meditation and nutrition but also psychology, interpersonal relationships, ethics and philosophy. Over time, many different yoga practices have evolved. Some are still original and from India; others have been developed in Western cultures and they primarily focus on physical fitness and wellness. Some kinds of yoga can be soft, challenging, relaxing, meditative or acrobatic. Some of the most important ones are: Hatha Yoga Hatha Yoga is the most well-known kind of yoga in the Western World and there are many schools and ways of doing it. Its focus is on the balance between body and soul which can be acquired through physical exercise and body control. Breathing exercises and/or meditation can also be part of some Hatha Yoga practices. Gyan Yoga Gyan Yoga is the yoga of knowledge. The goal is to experience truth through practice and knowledge and to see god or rather the divine in everything. Kundalini Yoga Kundalini Yoga is also called yoga of awareness. The balance between body and soul can be achieved through physical exercise, relaxation, meditation, the use of Mantras (syllables or words that are recited), Mudras (gestures performed with the hands), Bandhas (“body locks", namely muscle contractions) and Pranayamas (breathing techniques). Kundalini Yoga can help you to control your mind, the power within you and a higher consciousness is aspired. Naad Yoga Naad Yoga makes use of the power of sound. Different sounds, mantras, musical instruments, the voice etc. create vibrations which have an effect on the body and can help to clear the mind. For people with SCI all these kinds of yoga are suitable that do not include acrobatic body positions. Important parts of regular yoga practice for people with SCI include meditations and breathing techniques (Pranayamas), which can have a palliative effect on breathing difficulties. Kundalini Yoga and its benefits for people with SCI Many workshops have proved that Kundalini Yoga is very well suited for people with SCI. This is because... ... many exercises (Asanas) can be performed in a sitting position or while lying on the floor. By this, sequences of exercises (Kriyas) can be developed for every lesion level. ... Kundalini Yoga especially focuses on breathing techniques. They train and increase the lung volume. ... concentration and mediation are a fundamental part. ... in Kundalini Yoga also relaxation and body awareness are stimulated and increased. ... respect for yourself and others is part of the Kundalini Yoga philosophy and its exercises and meditations.   Yoga exercises in the wheelchair…   … and on the floor With regular practice, Kundalini Yoga can have very positive effects on the body and mind for the practising person. Some reasons are: muscle growth and stretching regulating effect on organs and organ functions (e.g. kidney, digestion) improved breathing and lung volume improved body awareness reduction of stress and increase of inner peace and serenity reduction and eventual overcoming of anxieties reduction of medical conditions that are caused by stress (e.g. digestion problems and tensions) reduction of muscle tension regulating effect of heart and breathing frequency and potentially lowering of blood pressure increase of ability to concentrate stimulation and sharpening of self-awareness reconciliation of the soul and subconscious – even spiritual blockades can be overcome With the permission of a doctor Kundalini Yoga is suited for everyone. The physical exercises can be practised and visualised and to engage in breathing techniques and meditation is possible even for people with a higher lesion level. People with SCI have to learn to listen to their body when doing yoga – just like anybody else. Additional information: http://www.mindbodysolutions.org/yoga/adapative-yoga/ http://www.youtube.com/watch?v=Alr7U_Rrzis Sources: URL: http://www.kundaliniyoga-ak.de/ (retrieved September 15, 2014) Kuwert, A. (2014): Kundalini Yoga für RollstuhlfahrerInnen. Gross-Umstadt: YogiPress. Author: Antje Kuwert, yoga teacher and yoga teacher's instructor updated: September 2014
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Humans are predestined for movement – probably everybody knows the good feeling after having been physically active. This physical basic need doesn't change despite an SCI. It is therefore an important goal of first rehabilitation to avoid that people with SCI are less physically active and therefore suffer from reduced functioning, mobility and independence. Not getting enough exercise may not only influence the physical health and the well-being of a person but may also lead to an increase of mental issues – and this usually long after returning to everyday life after first rehabilitation. Studies have even shown that people who are less physically active tend to suffer more frequently from depression, anxiety and a decreased quality of life. Moreover, a fit and active body is less prone to co-morbidities. Due to breathing more deeply and an increased blood circulation during sports activities, the risk of urinary tract infections, respiratory diseases, increased spasticity and pressure sores is decreased – this applies for complete and incomplete paraplegia and tetraplegia. The physiological advantages for people with SCI of being physically active have been proven in numerous studies. Here are some examples: improved heart and respiratory functions; therefore increased endurance and performance improved coordination and physical capacity (less fatigue) improved muscle strength positive influence on the vessels and the blood flow (thrombosis prophylaxis) improved metabolism and prevention of increased cholesterol levels Archery Being physically active therefore does not only contribute to maintain and develop the physical skills but has also an important psychosocial component – not only for people with SCI. Regained passion and joy in physical activity may help to better cope with the new life situation. Enjoying physical activities is an important element for self-esteem and self-confidence and allows to not only test one's limits but also to increase them through training. Furthermore, being actively involved in a sports club or an interest group promotes social interaction and integration. For many people, sports is a good opportunity to meet other people, not only with SCI but also pedestrians, and to make friendships. To keep moving does not only mean staying alone at home or in the gym and "grinding out kilometers" but is an interesting and communicative leisure activity, especially within a group. The choice of disciplines for people with SCI is more diverse than one can imagine. The website of the Paralympic Committee gives a good idea of what may even be done as high-performance sports in competitions (www.paralympic.org). Which sport is most suitable, can be determined in a rehabilitation facility or together with a physiotherapist or sports therapist who is experienced with people with SCI. As early as 1948, the physician Sir Ludwig Guttmann understood that sports play a very important role during first rehabilitation of people with SCI. His commitment resulted in the first Paralympic Games in 1960. Ever since, the repertoire of disciplines of the Paralympics has been increasing constantly. Some sports disciplines are still in their beginnings; however, many of them established themselves many years ago and are very popular within the community. Depending on lesion level and physical skills, the following sports disciplines may be an option (small selection): Athletics This sport is popular with incomplete and complete paraplegics and tetraplegics (people with spina bifida and amputations are usually integrated into respective competition classes). During national and international sports events competitions regarding all common distances are held – from sprint to marathon. Wheelchair race Handcycling The handbike is not only a very suitable means of transport but allows for a very gentle way of doing sports. Since the shoulders of most people with SCI are heavily used through the daily propelling, they often get problems with the tendons and muscle attachments. As shown in a study, handcycling is not only more efficient, but puts also less pressure on the shoulder girdle. There are competitions in various classes over various distances. Handbike Basketball The "bodiless" sport, as basketball is also called, is especially popular among people with paraplegia. Not only physical endurance and balance is required but also team spirit and the ability to overview. Wheelchair basketball has been played since 1945, when American veterans put their national sport on wheels. Wheelchair basketball Rugby Similar to basketball, rugby is a very active and fast-paced team sport that is mostly played by tetraplegics (Low Point Rugby). Specially designed wheelchairs protect the players from injuries, when the athletes crash against each other with their sports devices. Also here, endurance, skills, team spirit and strategy are important elements of the game. Wheelchair rugby Tennis Another ball sport that is played in over 100 countries and has also been a discipline of the Paralympics since 1992 is tennis. The rules of the game are identical with those for pedestrians – the only exception is that the ball may touch the ground twice before it needs to be hit. In order to be able to play tennis, the hands and arms need to be fully functioning. Tennis is therefore especially suitable for paraplegics with a low lesion level. Skiing Even though skiing is not possible everywhere and also very time consuming and needs many resources, it is a very popular mass sport. One would assume that skiing is only possible for people with a low lesion level but also people that do not have a sitting balance can enjoy the sport on the slopes in the skibob. Depending on the independence of the person, an person assisting is needed. Monoski (Source: W. Morelli) The range of possible sports activities is much wider: Even fun sports such as surfing, climbing, wheelchair skating and motor sports (quad bike riding) but also dancing and yoga are possible depending on the physical prerequisites. Especially people with tetraplegia dedicate themselves to target shooting (archery among others) or e-hockey (hockey on electric wheelchairs for tetraplegics). As long as one enjoys exercise and it is good for body and mind, it does not matter which sport you choose. It is recommended to try out the various sports offered within the regional wheelchair clubs or associations after consulting a health professional. In Switzerland the sport consulting services and promotion offered by the Swiss Paraplegics Association (www.spv.ch) are very well organized. Especially the regional wheelchair clubs are an ideal meeting point to get in touch with other people and learn new things. Wheelchair skating updated: December 2013
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Libido – the desire for sexuality Libido is the desire for and pleasure in sexuality. In men, it depends on a certain amount of the sexual hormone testosterone and in women, the hormone oxytocin plays an important role. Libido is triggered through the senses, e.g. through touching, pictures, taste, smell or music. People with spinal cord injury may have as much desire as people without SCI since the above mentioned factors, except for sensitivity, are hardly influenced. Depression or medication against depression (antidepressants), pain medication (opiates, neuroleptica), spasticity reducing medication (diazepam), and for women the birth control pill, may reduce libido. Sensuality Spinal cord injury often causes loss of sensitivity of the skin. Touching can no longer be sensed or is sensed differently on certain body parts (below the lesion level). This may be experienced by the person affected as a big loss. Unfortunately, there is no therapy for this issue so far. There are, however, possibilities to partially compensate for these deficits and limitations of sensitivity of the sexual organs. So far unknown erogenous zones may develop or be discovered, for example on the nape of the neck or behind the ear. Furthermore it is possible to stimulate the sensory organs that are intact even more, e.g. through erotic music and sounds, sweet words, tantalizing clothes, bed linen or lingerie, a glass of sparkling wine, sensually appealing lighting, mirrors to sense the touching with the eyes, various materials to spoil the sensitive body parts (silk foulards, feathers, skins, etc.), or beguiling fragrances such as ylang-ylang, jasmine, sandalwood, vanilla or musk. Facial and body oils, balsams and also essences for a fragrance lamp or candles can pamper the olfactory sense. Oysters, caviar, truffles, tomatoes, asparagus, coconuts, hazelnuts or a bit of grated nutmeg are said to have an aphrodisiac effect. Anchovies, radishes, chilly, pepper and mustard are supposed to be “a turn on" while parsley, ginger, sage and celery can be used to stir up hunger for love. Add figs, chocolate, strawberries, cinnamon or bananas to make sensual moments even sweeter. People with disabilities may learn that sexuality can be a most pleasurable and delightful experience, also without all the body functions working properly. Tantric rituals allow you to feel and experience your partner using all of your senses – they are available on DVDs, such as „Tantra & Selbsterkenntnis für Paare“ („Tantra and self-awareness for couples" (see below). Positions Various positions for making love can also be performed by people with SCI. Variation increases libido as well as pleasure and allows for different kinds of touching and sensing. The more open and direct everybody involves, the more pleasurable the encounter will be. The partner can help stabilizing a certain position; often it is enough to just give a little bit of support to change position. Also ramps and cushions, positioned under the woman's hip for example, or straps that are attached to the ceiling are useful aids. Rider Rider 1 (Source: IntimateRider) Rider 2 (Source: IntimateRider) Men with SCI can use a swing chair called the “IntimateRider" in order to play the active role during the love play. The specific design of the seat allows moving it with very little pushing effort causing your pelvis to move for easy thrusting during sex. The bench helps to position the partner in an optimal height. Bedding pillows Bedding pillow 1 (Source: IntimateRider) Bedding pillow 2 (Source: IntimateRider) Bedding pillow 3 (Source: IntimateRider) Prerequisites for sexuality Being able to relax and overcome uncertainty or fear – one's own or the partner's – is a pre-condition for a fulfilling sex life. Handling fear productively makes it possible to experiment, to be curious and open for pleasurably experiences. This may refer to one's physical condition, the position in which you feel comfortable and attractive or the kind of stimulation one whishes for. It is possible to experiment with the surrounding, decoration, room temperature and lighting or necessary aids. Another important pre-condition may be an informative conversation with the partner. People with SCI need to learn to take factors and conditions into account that were not important or were ignored before the injury. Being aware of your own needs, being able to deal with them and to stand up for them may be an enhancing step towards a fulfilled sex life. Fear may decrease libido The changed situation after SCI may cause fear in the first place: fear of failing, of not pleasing somebody or not meeting somebody's expectations; fear of incontinence or of spasticity. This may be experienced as exhausting or not pleasurable for everybody involved. On a permanent basis, this may cause loss of interest in sexuality. Therefore people with SCI, their partners and the whole rehabilitation team of professionals need to be informed about the problems. This is the only way to address and discuss fears and search for solutions. If these problems are not addressed, they are being made a taboo. Moeller writes in 1998 “Was man tabuisiert, kann man nicht gestalten"; meaning that things that are being made a taboo cannot be changed. Fear of incontinence Managing bladder and bowel functions is very important. People with SCI learn a lot about their body over the years and they will be careful to empty the bladder (and maybe also the bowel) before having sex, to reduce the amount of drinking and to keep an underlay handy. Informing the partner beforehand that unpredictable physical reactions might happen and knowing how the partner will react can help to relax. Furthermore, sex naturally never happens without excretion of sweat, saliva and sperm liquid. Keep in mind that saliva is much less hygienic than fresh urine. Also, sex does not necessarily need to happen in the bedroom: a meadow, the shower or bath tub are amazing places where fear of incontinence is not an issue. Ducharme & Gill (2006) write that, understandably, most people with SCI are afraid of bowel accidents. However, if they follow a regular scheme for emptying the bladder and bowel, there is no reason why sexual activities should interrupt this pattern. […] The most important part is to talk to your partner about this topic and being prepared should an accident happen. Keep a towel handy. If your partner knows about your worries, it may reduce your tenseness and increase sexual pleasure. Fear of not having an erection Despite all aids and medications, many men are afraid of not having an erection. Pictures of highly potent men have been internalized and sex is often being confused with high performance sports. However, sex is not an Olympic discipline – the goal is not higher, faster, better – there is not even a goal to be reached. A man often thinks a woman would leave him if he cannot have a proper erection. This is not the case! Which woman would not like to take care affectionately by taking it easy, fooling around, massaging each other, saying sweet things or listening to music while snuggling together tightly? Men with an erectile dysfunction absolutely need to inform their (new) partner about it. They cannot assume that everybody knows about erectile dysfunctions and SCI. This might be misunderstood by the partner and therefore the partner may look for the problem in him-/herself, such as not feeling attractive, not being able to please and therefore not causing an erection. Fear of spasms and spasticity Spasms are uncontrolled muscle movements that are often perceived as shaking. They can be caused by various stimuli such as change of position, a full bladder, touching the skin, sexual arousal, or, completely unpredictable within the disabled body parts. Spasms might be hindering, like for example when finding a certain position, but they can also be used to reach a better erection or movement of the pelvis. Spasticity (increased body tension) can mostly be stopped by changing the position or through a massage. In general it is very helpful if the partner is informed about the fact that spasticity or spasms might occur. Fear of autonomous dysreflexia Manipulating on the sexual organs, sex, gynecological examinations, the last phase of pregnancy and child birth may cause an autonomous dysreflexia. Symptoms may be headache, vertigo, cold sweat on the skin above the lesion level, a red face and a fast increasing blood pressure while the pulse is going down. This can be treated by stopping the cause, for example stimulation of the genitals. If this is not possible, it is recommended to lower the blood pressure through medication. In most cases, the symptoms disappear immediately after stopping stimulation. The people affected need to be informed in a sensitive way about what can be done to stop an autonomous dysreflexia and which precautions need to be taken. Sexual guidance and sexual assistance People with disabilities may have more difficulties than people without disabilities in getting access to sexuality with a partner or with masturbation. Since the nursing staff is not allowed, and does not want to, assist sexually, a special form of prostitution – sexual assistance and sexual guidance – has developed. Sexual guides enable their customers to make erotic-sensual experiences through touching, holding, caressing or hugging. The goal is to experience closeness, a feeling of security, relationship and contact, warmness, tenderness, pleasure and sexual satisfaction. Sexual guidance may also assist people with disabilities to make their first sexual experiences. Most of them do not offer (oral) sex. Passive sexual assistance means assistance with getting sexual utensils such as porno movies or vibrators, or preparative measures such as transportation to a prostitute, helping to undress for sexual intercourse or support with finding a partner or prostitute. Most institutions (hospitals, care facilities, etc.) do neither have the amenities nor staff for offering such services. Therefore sexual assistance needs to be organized privately. Services offered by specifically trained sexual therapists and counselors can be found e.g. in the internet. FAQ Can the medication that I am taking on a daily basis have an influence on my libido? Yes, there is medication that is known for reducing libido. If you have the feeling that this is the case, it is, however, important that you talk to your urologist before changing medication. Do not stop taking medication without consultation of a professional! Suggestions for literature and DVDs Sexualität trotz(t) Handicap Authors: Christiane Fürll-Riede, Ralph Hausmann, Wolfgang Schneider Publisher: Georg Thieme Verlag, Stuttgart Year of publication: 2001 ISBN: 978-3131182111 Sexualität bei Querschnittlähmung Antworten auf Ihre Fragen (Sexuality After Spinal Cord Injury: Answers to Your Questions) Authors: Stanley H. Ducharme, Kathleen M. Gill Publisher: Verlag Hans Huber, Bern Year of publication: 2006 ISBN: 978-3456839332 Sexualität und Behinderung: Umgang mit einem Tabu Authors: Hans-Peter Färber, Wolfgang Lipps, Thomas Seyfarth Publisher: Attempto Verlag, Tübingen Year of publication: 1998 ISBN: 978-3893082933 Hautnah Neue Wege der Sexualität behinderter Menschen Authors: Lothar Sandfort Publisher: AG SPAK Bücher, Neu-Ulm Year of publication: 2007 ISBN: 978-3930830305 Behinderung und Sexualität: Probleme und Lösungsmöglichkeiten Author: Hermann B. Offenhausen Publisher: Reha-Verlag, Remagen Year of publication: 2006 ISBN: 978-3882390612 Sexualität und Querschnittlähmung Nicht vorbei Die Therapie neurogener Sexualstörungen Praktische Ratschläge für den Alltag (DVD) Source: Dr. med. Dieter Löchner-Ernst BG Unfallklinik D-82418 Murnau www.nichtvorbei.de e-Mail: info@nichtvorbei.de Tantra & Selbsterkenntnis für Paare (DVD) Director: Dirk Liesenfeld Studio: Intimatefilm (AL!VE) Year of publication: 2011   References: Ducharme, S.H. & Gill, K.M. (2006): Sexualität bei Querschnittlähmung. Antworten auf Ihre Fragen. Bern: Verlag Hans Huber. Moeller, M.L. (1998): Worte der Liebe: Erotische Zwiegespräche. Ein Elixier für Paare. Reinbek bei Hamburg: Rowohlt.   About the author: Therese Kämpfer is responsible for patient education in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1999. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas) and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
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Lubrication (vaginal lubrication) Lubrication is a lubricating fluid that is secreted by glands during sexual arousal. Lubrication occurs during the peak period of sexual arousal and facilitates penetration. Depending on the level of paralysis, women with spinal cord injury (SCI) might show fewer or no physical signs of sexual arousal. However, this does not mean that they are not aroused. Psychogenic lubrication Attractiveness and charisma of the partner are effective psychological stimuli that can evoke lubrication. Odors, visual and acoustic stimuli, as well as one's own imaginations, expectations and sexual desires might also cause psychogenic lubrication. The brain analyzes these stimuli and transmits the information through nerve fibers to the spinal cord and subsequently to the vagina – this is when lubrication starts. Psychogenic lubrication can basically occur in paraplegic women with a spinal cord injury below the Th11 level – in case of a complete paralysis above Th11, lubrication is rather unlikely. Reflexogenic lubrication Reflexogenic lubrication occurs through direct stimulation of the genitals. The stimuli are transmitted to the reflex centre in the spinal cord and are processed. Then nerve fibers transmit the stimuli back to the vagina and lubrication starts. Reflexogenic lubrication is only possible in paraplegic women with a spinal cord injury above the level of the reflex center (S2-5). Reflexogenic lubrication does not occur in women with a complete, low-level paralysis. However, there are numerous exceptions and therefore, it is difficult to make general statements. Assistive Devices If the vagina is too dry, the use of lubricants can facilitate penetration of the penis or sex aids. Oils, Vaseline, water or silicone-based lubricants can be applied. In case condoms are used, no fat-based lubricants should be used, as these can cause microscopic cracks in latex condoms. Oils and Vaseline are therefore not suitable for safer sex. Lubricants are available in pharmacies, drugstores, supermarkets, and sex shops. Orgasm Depending on the level of paralysis, women with SCI can have orgasms or not. Women with SCI do no longer sense the physical stimulation of the genitals and the pelvic area as intense as they have done without SCI. The orgasm is rather sensed differently, e.g. as comfortable and warm feeling in the pelvic area, not at all or even as unpleasant. The unpleasant feeling can be caused by spasticity occurring in the legs or the abdominal area or by an autonomous dysreflexia. Furthermore, it takes longer to achieve orgasms than before the SCI. “Women often report of so-called 'para-orgasms'. This means: in contrast to genital orgasms, the orgasm experienced by these women is of unique quality. It can be a combination of physical sensations, emotional reactions, memories, imaginations and visual and/or acoustic stimuli – therefore, these orgasms are holistic body experiences, that are not limited to the genital area." (Ducharme & Gill, 2006). Fertility Menstruation might stop right after a traumatic spinal cord injury, but will start again after 2-12 months. Conception is absolutely possible in women with SCI, as the necessary functions are not controlled by the spinal cord: when a woman is born, her ovaries already contain all the ova she will ever produce, oogenesis and ovulation are controlled hormonally and the transport of the egg through the fallopian tube to the uterus is ensured by uncontrolled muscle movements of the fallopian tube and by the movements of the cilia. Contraception The absence of the menstruation following spinal cord injury does not necessarily mean that the woman is protected against pregnancy. Contraception is therefore recommended. Basically, all common contraceptive methods are suitable for women with SCI. The different methods have pros and cons – it is therefore important to talk to your gynecologist before choosing one: hormonal contraception with estrogens (birth control pill) increases the risk of thrombosis. Methods based on temperature monitoring may not be reliable in women with spinal cord injury. Frequent infections or tetraplegia-related temperature regulation disorders can affect body temperature. Mirena The application of the hormone spiral Mirena is recommended. Mirena exerts its effects locally in the uterus and thus ensures a long-lasting, extremely reliable protection against pregnancy. A flexible plastic cylinder containing a hormone that has been used in contraceptive pills for many years is placed in the uterus. Mirena releases small amounts of the hormone locally into your uterus at a slow and steady rate – there it starts to work. Thus, the rest of the body is only minimally affected by the hormone (approx. 20 times less compared to micro pills) – Mirena is therefore associated with fewer side effects than contraceptive pills. Hormone spiral Mirena How does Mirena work? Hormone spiral Mirena in the utero (Source: Bayer HealthCare) Mirena thickens the cervical mucus to prevent sperms from entering the uterus Sperm mobility is reduced. The hormone also prevents the uterus lining (endometrium) from thickening each month. This stops any eggs from successfully implanting onto the wall and thus naturally reduces the menstrual bleeding. With the absence of monthly periods, tampons and pads no longer need to be changed. Pregnancy Women with SCI can experience completely normal pregnancies; however, some things have to be considered or done: Earliest possible cooperation between gynecologist, paraplegiologist and midwife. Make sure your medication does not harm the embryo Physiotherapy, elevation of legs, compression stockings or medication to prevent thrombosis. Pregnant women should learn how to palpate the abdomen by themselves, in order to control labor (abdomen is hard, uterus grows upwards). In case of no sensitivity, the pregnant woman needs to know which signs might possibly indicate labor. Most women know their body very well and know exactly what kind of symptoms replace pain, e.g. spasticity, feeling of pressure, headache, and goose bumps or sweating. Adaptation of assistive devices, e.g. wider wheelchair, new seat cushion to compensate weight gain and thus prevent decubitus, wheelchair accessible cot Pay attention to any signs of autonomous dysreflexia: the closer the delivery date, the higher the risk. Adaptation of delivery date: women with SCI usually deliver prior to the expected date of delivery. Tetraplegic women generally deliver 24 days earlier, paraplegic women 5-6 days earlier. This is usually no problem for the baby. The expectant mother is thus spared the last and most difficult weeks of pregnancy. Delivery It is basically possible to experience a spontaneous delivery without complications also if the mother is not able to actively assist. The uterus has an independent conduction system that significantly influences delivery. In most cases, completely relaxed abdominal and pelvic floor muscles facilitate delivery. In case of delay in the second stage of labor, instrumental vaginal delivery is recommended (forceps delivery, ventouse). The indication for a c-section is the same as in women without SCI. However, the situation is more difficult in women with high-level paraplegia or tetraplegia with autonomous dysreflexia. Symptoms that may indicate autonomous dysreflexia can be headaches, sweating, and slow pulse and impeded nasal breathing as a result of a swollen mucous membrane. Due to these possible complications, women with spinal lesions at Th6 or above require regional anesthesia when delivering. Abortion Abortion can be induced by medications or surgical procedures, such as vacuum aspiration or scraping (curettage). In women with a sensitive complete paralysis, this should be performed under anesthesia, in order to prevent autonomous dysreflexia. Medical check-up The annual medical check-up is also part of the health protection in women with SCI. However, only very few gynecological practices can provide the necessary infrastructure or auxiliary staff, who are trained to help women with SCI adequately with dressing and undressing or transferring and who, at the same time, have an in-depth knowledge of spastic reactions and joint restrictions in the hips. In addition to that, a vaginal examination can cause an autonomous dysreflexia. The gynecologist should be informed about possible complications in good time. Reference: Ducharme, S.H. & Gill, K.M. (2006): Sexualität bei Querschnittlähmung. Antworten auf Ihre Fragen. Bern: Verlag Hans Huber.   About the author: Therese Kämpfer is responsible for patient education in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1999. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas) and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
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Erectile dysfunction Men with spinal cord injury (SCI) may experience erection problems, also called “erectile dysfunction". This is the case if it is permanently impossible to have an erection that lasts long enough for having sexual intercourse. It depends on the level of SCI and whether it is a complete or incomplete SCI. In general, however, the higher the level of SCI, the more likely is the ability to have a complete reflexogenic erection and to maintain it. If the level of SCI is low, chances to be able to have a psychogenic erection are higher. Men with spastic paralysis have higher chances of being able to have an erection than men with a flaccid paralysis. Erection problems can show in various ways: spontaneous erections or erections in the morning are usually impossible; the penis does not become hard or hard enough to penetrate the partner despite sexual stimuli; the erection lasts only for a short time and diminishes before or shortly after the man can penetrate the partner. Various types of erection Psychogenic erection The force of attraction and charisma of the sexual partner are efficient psychological stimuli that may lead to an erection. Smells, optical and acoustic stimuli, as well as your own imagination, expectations and sexual desires may provoke a psychogenic erection. Evaluation of these stimuli is done by the brain. From there the message goes through the nerves to the spinal cord and finally to the penis which results in an erection. Men with SCI can, in general, have a psychogenic erection if the level of SCI is below Th11 to L2. However, the erection can only be maintained as long as the brain is stimulated, which is usually only for a short period if an additional reflexogenic erection (see next paragraph) is not possible. Reflexogenic erection Reflexogenic erection is triggered by physical touch and caressing of the genital area. The stimuli are forwarded to and processed in the reflex centre located in the spinal cord. From there the message goes through the nerve fibers to the penis and triggers an erection. A reflexogenic erection is only possible if the level of SCI is located above the reflex center (S2-5). If there is no signal coming from the brain (psychogenic erection (see paragraph before)), permanent stimulation is necessary in order to sustain the erection. This is often not enough and too short for sexual intercourse. It is most likely that both forms of erection are possible if the level of SCI lies between Th11 and S1. There are many exceptions, however, and it is therefore difficult to make a universally valid statement. Medical treatment of erectile dysfunction Medication Treatment of an erectile dysfunction is mainly done through medication. The best products are currently from the group of the PDE-5-Inhibitors. Sildenafil (Viagra) has been available since 1998 and has shown excellent results in studies that have also been conducted with paraplegics. Other drugs from the same category are Tadalafil (Cialis) and Vardenafil (Levitra, Vivanza). Generally, these drugs are made of the same components. However, this does not mean that if one of the products did not bring the result hoped for, the others will not bring any success either. Tadalafil is different from the other two products through its prolonged effectiveness (36 hours versus 4-5 hours). These drugs only become effective in combination with sexual stimulation. Important These drugs must under no circumstances be combined with any nitroglycerin products since this may cause a life threatening condition where there is not enough blood circulation in the heart. Nitroglycerin products (e.g. in case of blood pressure crises) are often used for people with SCI suffering from an autonomous dysreflexia. Medication with natural ingredients There are plants that contain a potency increasing ingredient, for example ginseng or maca, a tuber plant from the Andes in Peru. The leaves and bark of the yohimbin tree can help with erection problems. The active substance of this plant can be found in natural drugs, the maca tuber for example in Androxan600 Forte. Another natural drug that supposedly has potency increasing effects is Libidoxin. Compared to PDE-5-Inhibitors, this drug mostly shows a less strong effectiveness. Corpus cavernosum-autoinjection (CCAT) for treatment of vasculogenic impotence Ever since new medication, namely pills, have been available, CCAT is not as popular any more as before. For some patients, however, this therapy is still important, especially if the medication does not work or cannot be applied. During this therapy, an active substance (Alprostadil) is being injected into the penis. The substance spreads throughout the erectile tissue and increases a unidirectional blood flow through relaxing the muscles, while at the same time hindering the blood to flow out. This causes an erection. This effect will occur independently from whether there is a sexual stimulation or not. In tetraplegic people, the partner may be instructed how to perform the injection. How does CCAT work? Corpus cavernosum-Autoinjection-treatment (SKAT) (Source: Onmeda) The erectile tissue is being punctured with a syringe: After careful cleaning and disinfection of the puncture spot with an alcohol swab, the drug is injected close to the body on the upper right or left backside of the penis. Avoid injecting into visible veins. An effect can be expected after five to ten minutes. Dosage should be chosen so that the erection does not last longer than 60 minutes. The puncture spot and sides of the penis need to be changed for every application. Before starting with the first application by the patient himself, the dosage needs to be tested by the physician in charge. CCAT needs to be prescribed by an urologist. Mechanical aids External vacuum therapy The external vacuum therapy is a mechanical therapy. This erectile aid is a plastic cylinder that is put over the penis and pressed to the base of the penis. A pump helps to create a vacuum which makes blood flow into the erectile tissue and the penis becomes hard. In order to maintain the erection, a penis ring is moved from the cylinder onto the base of the penis to prevent the blood from retreating prematurely from the erectile tissue. For men with SCI, this solution often does not work well since the penis can bend at the base. The penis ring must be removed after sexual intercourse since the pressure might cause damages or necrosis. Vacuum-Pump (Source: AMEDS Centrum/VEDI Clinic) Penile prosthesis The penile prosthesis is a surgical therapy during which two plastic cylinders are implanted into the erectile tissue bodies. The plastic cylinders can be filled, if required, through a pump that is implanted in the scrotum. This hardens the penis mechanically. There is a risk of infection and mechanical defects. Furthermore, this surgery destroys most of the erectile tissue. Corpus cavernosum-implant (Source: AMEDS Centrum/VEDI Clinic) Modified orgasm The ability to have an orgasm is almost always affected through SCI. The rhythmical, spontaneous muscle contractions that occur during an orgasm may prevail longer after SCI and may be perceived as unpleasant by the person affected. If the SCI level is above Th12, the orgasm is often preceded by spastic reactions in the legs. In case of a sensitive incomplete paraplegia, the orgasm sensations can be similar to the ones before SCI. People with a sensitive complete paraplegia in the genital area report that it is possible to experience an “orgasm in the head" or that they may experience an overall feeling of well-being and relaxation as they know it from before the injury. In this case imagination, adventurousness and pleasure in experimenting play an important role. Some paraplegics and tetraplegics experience orgasms despite reduced or missing sensitivity. Ejaculation When ejaculating, various nerves work together. After SCI they often do not work together properly anymore and this creates problems for ejaculation. Ejaculation may then happen only in drops, not at all or retrograde into the urinary bladder if the valve of the bladder neck does not work. Fertility Also after SCI, a man is able to have children of his own. Sexual functions such as erection and ejaculation may remain preserved as well as a sufficient quality of the semen. If these functions are limited or missing, there are various possibilities to have children. They are described in the following paragraph. It is generally recommended to inform oneself ahead of time since also the biologic age of the woman plays an important role when planning a family. After spinal cord injury, the quality of the sperm is almost always lower than before. There are numerous study results explaining the reasons for often severely decreased fertility after SCI. It was assumed that influences through changed living conditions such as an increased temperature of the testicles through the sitting position in a wheelchair, ejaculating rarely, and infections of the urinary tract, antibiotics, and histological changes of the testicle tissue or the duration of paraplegia might be the reasons but this could not be confirmed. Since all organs, that have an influence on the quality of the sperm, are controlled by the autonomic nervous system, the assumed cause lies here. Freezing the sperm (cryoconservation) is generally possible if requested. It needs to be considered, however, that through thawing the stored semen, the mobility and vitality of the sperm decreases considerably compared to before freezing them. Moreover, since the quality of the sperm does not decrease the more time goes by after SCI, it is recommended to use a fresh sperm sample. However, using previously frozen sperm may principally be used to conceive a child. Having children Intrauterine insemination If there is a sufficient number of mobile sperm, intrauterine insemination (using a catheter through the cervix, the sperm is transferred directly into the uterus of the woman) can be undertaken. However, the number of paraplegic men with a sufficient sperm quality is low. Intracytoplasmic sperm injection (ICSI) If the sperm quality is low, but a few mobile sperms can be found, an intracytoplasmic sperm injection (ICSI) may be used. ICSI is an artificial fertilization procedure in which a single sperm is injected directly into an egg. Through assisted ejaculation (see next paragraph) and ICSI, it became possible also for paraplegic men to have children since per egg only one mobile sperm is needed. Intracytoplasmic sperm injection (ICSI) (Source: Kinderwunschzentrum Regio Basel) In order to determine the sperm quality, it is necessary to have a spermiogram done (examination of the sperms using a microscope and analyzing the sperm liquid). High quality spermiogram Low quality spermiogram A therapy to increase the sperm quality has not yet been found. To retrieve sperms, a vibratory stimulation of the penis can be used. Vibratory stimulation of the glans causes ejaculation if the sacral reflex arc functions. If no ejaculation can be achieved, there is the possibility for rectal probe electro stimulation. Electrodes are inserted into the rectum which causes stimulation of certain nerves and therefore discharge of semen. This method does not depend on the sacral reflex arc and can therefore also be used for paraplegic men with a level of SCI below L3. If this method also does not bring the desired success, sperms can be retrieved through surgery from the testicular tissue. FAQs Can medication, that I am taking every day, have an impact on my libido? Yes, there is medication that is known for decreasing libido. If you have the feeling that this applies in your case, it is, important that you only change your medication after having talked to your urologist. Do not stop using medication based on your own decision only! Is medication for treatment of erection problems paid by my health insurance? It depends. Usually, in Switzerland the tablets are not paid for; however, the injections (CCAT) are paid. Can I consult any urologist if I suffer from erection problems or if I and my partner want to have children? It is recommended to consult an urologist that is highly experienced with paraplegia. Best thing to do would be to consult your current urologist from the SCI center. Reference: Ducharme, S.H. & Gill, K.M. (2006): Sexualität bei Querschnittlähmung. Antworten auf Ihre Fragen. Bern: Verlag Hans Huber.   About the author: Therese Kämpfer is responsible for patient education in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1999. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas) and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
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A person can be described in different ways. In psychology different models, theories and classifications exist. For example, “the big five model” describes a person’s personality according to how open (curious, creative and adventurous), how conscientious (self-disciplined and dutiful), how agreeable (friendly, generous and helpful), how extravert (interacting with people, enthusiastic, action-oriented) and how neurotic (being emotionally reactive and vulnerable to stress) the individual is. Some classification systems were developed to capture a person’s vulnerabilities, such as being depressed, anxious, or disruptive/impulsive, to be able to provide support and appropriate treatment to this specific person (Diagnostic and Statistical Manual of Mental Disorders (DSM-5)). Other classifications can help to indicate a person’s strengths and resources, such as optimism, kindness or gratitude to better support people in their individual ways towards feeling more well and happy (Values in Action Classification of Character Strengths (VIA)). When dealing with a physical injury, such as a spinal cord injury, the affected person is confronted with many challenges and all facets that constitute a person need to be considered. The group of psychologists working at Swiss Paraplegic Research (SPR) focus more on “building what’s strong” rather than “fixing what’s wrong” and pursue a resource and strengths-oriented approach to research. With their research endeavour the group aims at the support of persons living with a disability and their families in providing them with useful information on how they can better deal with their injury and its consequences. This article introduces the reader to some of the most “powerful” strengths and resources of a person. Powerful, because a great deal of research confirmed that these strengths and resources of a person are strongly related to well-being and happiness. The following paragraph will list these strengths, what they mean and comprise, and what today’s research knows about their relevance. Gratitude Gratitude is a felt sense of wonder, thankfulness, and appreciation for life. There are many things, both large and small, in our lives that we might be grateful for. These might be particular supportive relationships (e.g., our parents, a close friend or even our dog or cat), sacrifices or contributions that others have made for us (e.g., teacher, neighbour or doctor), facts about our lives such as our advantages (e.g., being creative, smart), opportunities (e.g., having an education, different interests) and circumstances (e.g., living near the lake, enjoying the landscape or city on the way to work). The practice of gratitude involves a focus on the present moment, on appreciating life as it is today and what has made it so. Research shows that people who are consistently grateful are also happier, more proud and hopeful about their lives and even report better physical well-being. Appreciation of good things in life bolsters self-worth and helps when dealing with stressful life events. Being thankful motivates helping others, thereby building and strengthening social bonds. It prevents people from taking good things in life for granted and prevents negative feelings such as envy, bitterness, anger or greed. Optimism Optimism is a tendency to look at the bright side of things in life and to expect the best possible future. Optimists generally believe that people and events are inherently good, so that most situations work out for the best in the end. Optimistic strategies are, for example, noticing what’s right (rather than what’s wrong), seeking the challenge in every difficult situation, giving ourselves the benefit of the doubt or simply trusting that we can get through the day. However, optimism is not only about having a strong belief that we WILL get there but also HOW we believe we will get there. Research shows that optimists are happier, more energetic, have more success in their job, report better health, and live longer than pessimists. Optimistic thinking helps when dealing with stressful life events and trauma and keep persons investing effort in lifelong goals. Friendship and social relations Social relations are the key to health and happiness. Social relations act as a buffer to protect people against negative effects of stress. They convey the information of being loved, cared for, esteemed, valued and bestow a sense of belonging that provides fundamental purpose in life. Research shows that individuals living with a disability who have supportive relationships are healthier, less depressed, can better deal with and adjust to their disability, are more satisfied in life and live longer. Finally, the mere thought of a loved one can reduce the perception of pain. Kindness An act of kindness is a selfless act performed by people to either help or cheer up other individuals, for no reason other than to make these persons happier. It is giving for the sake of giving, not in order to receive something in return. There is a famous Chinese saying, which brings this to a point: “If you want happiness for an hour, take a nap. If you want happiness for a day, go fishing. If you want happiness for a month, get married. If you want happiness for a year, inherit a fortune. If you want happiness for a lifetime, help somebody else.” Why do acts of kindness make someone happier, healthier and their life longer? An act of kindness relieves stress and improves the mood by distracting from one’s own troubles and ruminations, it has a positive impact on self-evaluation and self-worth, enhances sense of meaning and purpose in life, and it also enhances social integration and strengthens social bonds. Savouring Savouring is generating, intensifying and prolonging enjoyment. It has a past, present and future component. We can savour the past by reminiscing about the good old days (e.g., our first love, summer camp or accomplishment of a degree), savour the present by completely immersing ourselves in a conversation, book, song or project at work, and savour the future by anticipating positive events (e.g., finalizing a project, an upcoming vacation or retirement). So savouring is not only living the present, it is also bringing the pleasure of the past and future into the present moment. Research shows that the ability to savour the positive experiences in life is one of the most important ingredients of happiness. Flow Flow is being so absorbed in what we are doing (e.g., painting, reading, woodwork, conversing, fishing, web surfing, or even working on a project at work) that we completely lose track of time. Nothing else seems to matter and we even fail to notice that we should go to the bathroom, eat or sleep. Flow is a state of intense and complete absorption and involvement in what we do. If the challenges of the situation overwhelm our level of skills we will feel anxious and frustrated, or if the activity is not challenging enough, we will become bored. Flow is just the right balance between our skills and challenges. Research shows that flow experiences produce intense feelings of enjoyment and, in the long run, lead to a strong sense of self, control, involvement and meaning in life, and happiness. Flow states are intrinsically rewarding, we want to repeat them. However, to maintain a flow state, one must seek increasingly greater challenges. Therefore, we are constantly striving, learning and growing, and become competent and successful in what we do. Goals Persons who strive for something personally important (e.g., learning a new language, a new sport or craft, changing careers, raising pets or volunteer in church) are far happier than those who do not have strong dreams and goals. The process of working toward a goal, participating in a valued and challenging activity, is as important for becoming lastingly happier as its attainment. Working towards a goal gives us a sense of purpose and control over our life, makes us feel efficacious and bolsters our self-esteem. Commitment to goals during times of crisis helps us cope better with problems. Forgiveness Forgiveness involves suppressing or mitigating one’s motivations for avoidance and revenge (often accompanied by emotions of anger, disappointment, and hostility), and replacing them with more positive or benevolent feelings, attitudes, and behaviours. Forgiveness is NOT condoning, reconciling, justifying, excusing, pardoning, letting go and moving on with one’s life, forbearing, or forgetting a transgression. We have forgiven when we have experienced a shift in thinking, such as that our desire to harm a person has decreased and our desire to do this person good has increased. Forgiveness is a gesture of supreme value. It is a mark of compassion, love, and caring. But forgiving is something that we choose to do for ourselves and not for someone else. Viktor Frankl, a psychologist and holocaust victim, wrote in 1959: “We must never forget that we may also find meaning in life even when facing a fate that cannot be changed. For what then matters is to turn one’s predicament into a human achievement. When we are no longer able to change a situation we are challenged to change ourselves.” Why should we forgive? Research shows that people who forgive report better physical well-being, such as a healthy heart rate and blood pressure, better immune functions, lower body tension and better quality of sleep. Forgiving people are less stressed, less likely to ruminate or dwell on revenge, are less likely to be hateful, hostile, angry and neurotic, are less depressed and anxious, show less fatigue and report a higher life satisfaction. Spirituality Spirituality is a search for meaning in life through something that is larger than the individual self. Spirituality is not only about sanctifying ordinary things on earth, it is taking care of our soul. Research shows that spiritual persons are happier and healthier, recover better after trauma and even live longer. Spirituality is very powerful as it is a source of self-esteem, feeling unconditionally valued, loved, and cared for. It embraces sense of security, hope and optimism, gives explanation and solace, emotional support, meaning and purpose in life. Finally, it helps to forgive and is a constant opportunity for personal growth. Physical activity and meditation Research shows that physical activity leads to not only better health, but also more self-esteem, mastery, energy, enthusiasm and vigour. Research also shows that meditation, which is basically about cultivating attention, is linked to better physical health, less depression, anxiety and pain, but also more serenity, peace and calm. Both physical activity and meditation embrace positive emotions, which not only make us feeling stronger, but distract us from worries, stress and anxiety. These strengths and resources can be promoted by therapies and simple exercises. Studies in the general population indicate that these therapies are effective to increase well-being and reduce depressive symptoms. Furthermore, a recent pilot study showed that these resource- and strengths-based therapies not only enhance happiness and reduce depression, but also diminish pain in individuals with a disability. Book suggestions: Seligman, M.E.P. (2011): Flourish: A visionary new understanding of happiness and well-being. New York: Free Press. Lyubomirsky, S. (2007): The how of happiness. A new approach to getting the life you want. New York: Penguin. Peterson, C. & Seligman, M.E.P. (2004): Character strengths and virtues: A handbook and classification. New York: Oxford University Press and Washington, DC: American Psychological Association. References: American Psychiatric Association (2013): Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Peterson, C. & Seligman, M.E.P. (2004): Character strengths and virtues: A handbook and classification. New York: Oxford University Press and Washington, DC: American Psychological Association. Sin, N.L. & Lyubomirsky, S. (2009): Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis. Journal of Clinical Psychology 65(5), 467-87. updated: December 2013
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A spinal cord injury (SCI) has severe consequences for the persons affected. The inability to control certain movements, restrictions in daily living or work, the loss of independence or the inability to participate in certain societal activities with friends, an insecurity regarding the future, one's personal role and expectations towards oneself are just a few examples emphasizing the huge challenges people with SCI might face. Considering all these challenges, one would expect that the well-being of persons with a spinal cord injury is severely affected by the disability onset. And indeed, people with SCI generally report lower levels of well-being than the general population. However, recent research shows that a majority of the persons with SCI are doing well. Many of them constantly report high levels of well-being after disability onset. Others show low well-being levels soon after the injury, but recover as time passes by. Some persons seem unable to function well for years after the injury and constantly report low levels of well-being. This group, however, represents a comparably small proportion of all affected persons. Why are these differences observed and what are the factors contributing to these differences? These questions have received considerable attention: knowing what factors influence well-being might be a first step towards targeted interventions aiming to support and enhance the life situation of persons with a spinal cord injury. Past research has yielded important findings that have led to a perspective change. Initially, it was assumed that all persons with SCI adjust in the same way. It was suspected that every person passes through a fixed set of stages, consisting of an initial shock after the injury, a denial of the injury with phase of anger, bargaining, depression and finally the acceptance of one's life situation. Empirical findings, however, have not supported this assumption. Every person reacts and adjusts individually to disability onset. Well-being after a spinal cord injury depends on many factors. It is important to highlight that the lesion level, as well as the severity of the injury, including bodily impairments, do not predict the well-being of persons with SCI accurately. Persons with a tetraplegia do not necessarily have a lower well-being than persons with paraplegia. Psychological resources and strengths, as well as how someone appraises and copes with the injury seem to contribute more substantially to well-being. Important factors among the personal resources are, for example, high self-efficacy (conviction or belief that one can successfully execute the behaviour required to produce a given outcome), purpose in life (the extent to which a person has life goals), self-esteem or an optimistic and hopeful outlook towards the future. For example, studies show that people with higher levels of self-efficacy report higher levels of well-being. How an individual appraises the injury can also contribute to an individual's well-being. Negative perceptions towards one's own disability or perceiving benefits and positive changes following the onset of spinal cord injury are examples of appraisals. Recent evidence suggests that persons evaluating their injury as a threat have lower well-being, while persons perceiving their life situation as a challenge report higher well-being levels. How persons cope with SCI, i.e. which efforts and behaviours they use to manage the demands imposed by their injury, is seen as a further important factor. Frequently, three broad types of coping reactions are differentiated: problem-oriented, emotion-oriented and avoidance-oriented coping. Planning and actively trying to solve a difficult situation constitutes a problem-oriented coping approach. Handling the emotions triggered by a spinal cord injury is an example for emotion-oriented coping. Denying or trying to avoid thinking of the current situation are examples for an avoidant-oriented coping strategy. Overall, the use of a problem-oriented coping strategy, such as planning, is associated with better well-being. In contrast, avoidance-oriented strategies are generally connected with lower well-being. Nonetheless, it is important to highlight that the empirical evidence regarding both appraisals and coping is not without inconsistencies. Psychological resources, appraisals and coping can be strengthened and modified by cognitive behavioural therapy or other specific programs. However, the degree to which the effectiveness of these programmes has been evaluated varies substantially. For example, evidence for the effectiveness of cognitive behavioural therapy is strong. The effectiveness of other intervention programmes, such as positive psychology exercise, is currently being examined and has yet to be confirmed. References: Bonanno, G.A., Kennedy, P., Galatzer-Levy, I.R., Lude, P., Elfström, M.L. (2012): Trajectories of Resilience, Depression, and Anxiety Following Spinal Cord Injury. Rehabilitation Psychology 57(3), 236-47. Eisenhut, J.: Funktionales Verhaltensmuster „Bewältigungsverhalten und Stresstoleranz“ – Verarbeitungsprozess. In: Haas, U. (Hrsg.) (2012): Pflege von Menschen mit Querschnittlähmung – Probleme, Bedürfnisse, Ressourcen und Interventionen. Bern: Verlag Hans Huber, 339-66. Peter, C., Müller, R., Cieza, A., Geyh, S. (2012): Psychological resources in spinal cord injury: a systematic literature review. Spinal Cord 50(3), 188-201. Post, M.W.M., van Leeuwen, C.M.C. (2012): Psychosocial issues in spinal cord injury: a review. Spinal Cord 50(5), 382-9. updated: December 2013
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Today strawberry yogurt is on Anna’s* grocery list. In front of the dairy section she notices that she cannot reach the yogurt sitting in a wheelchair. Many stressed people are rushing through the crowded store during rush hour and she does not dare to ask for help. Daniel* is just about to put his wheelchair into the car when a colleague from work comes by and wants to help him to pack it in the trunk. Daniel is annoyed about the help he did not ask for and also shows it, until his colleague walks away shaking his head. Nadine* is having a tough time. For having her pressure sore treated, she needs to go to the clinic. Her boss has noticed some mistakes she has done and she just had an argument with her boyfriend. She visits her sister and tells her how difficult everything is and how bad she feels. Her sister takes Nadine into her arms, comforts her and encourages her. As the three examples show, the right kind of support from the people surrounding us is important, not only for wheelchair users. Literature shows that people who have a supporting social network are physically and mentally healthier and indicate a higher quality of life. First data evaluation of the Swiss Spinal Cord Injury Study (SwiSCI) show the role that social support plays and how social skills influence the life of people with spinal cord injury. What are social skills? “The way we interact with each other” would be a simplified description of social skills. Psychology defines social skills as the ability to interact appropriately but also efficiently with other people. This means striving to reach one’s own goals while respecting the norms and values of others. Social skills include simple communication tools such as verbal (e.g. volume or pitch of the voice) and non-verbal aspects (e.g. eye contact, body posture) but also more complex strategies such as self-assertion, goal orientation and problem solving. More explicitly, social skills include encoding (expressivity) and decoding of information as well as control in social situations. Expressivity means to communicate understandably one’s emotions and needs to the listener but also to make contacts and to include others in a conversation. Sensitivity means being able to empathize with somebody else’s position and to sympathize with his/her emotions and thoughts (empathy). Self-control refers to being able to control one’s own emotions or anger, grief or enthusiasm, but it also refers to social “tactfulness”. Research shows that deficits in social skills are related to numerous psychological conditions such as depression, anxiety disorders or alcohol and drug abuse. For the area of physical disabilities, there are only few studies so far and it is unclear which role social skills play for people with spinal cord injury. What does social support mean? Examples for social support would be help with shopping, good advices from friends or being comforted by one’s sister. Therefore it must be differentiated between diverse kinds of social support (instrumental, informational, emotional) from various sources (e.g. family, friends, neighbours) that can be considered from different perspectives (e.g. quantity and quality). Social support is like a “buffer" that protects people from negative influences and stress. Research in the field of spinal cord injury shows that social support is important to prevent pressure. People who are satisfied with the social support they receive, are physically and mentally healthier, report less pain, are coping better with burdening life situations and indicate a higher degree of life satisfaction. Examining psychological topics within SwiSCI SwiSCI is the so far largest survey from a comprehensive perspective of people with spinal cord injury among the Swiss population. In the below described study participants are asked to fill out various questionnaires. In order to measure social skills, the participants needed to judge how much certain statements apply to them. Examples are “Usually I take the initiative and introduce myself to people I have not met before", “I am absolutely able to give the impression that I am calm, even though I am upset" or “I always seem to know what others truly feel". In order to measure social support, the participants were asked to list people on which they can count when they need help or support when asked e.g. “Who does really take care of you, no matter what happens"? They were also asked how satisfied they were with the support they received in this context. Furthermore, with the help of the questionnaires, data about possible depressive disorders or limitations within various areas of life as well as the degree of quality of life were collected. Results Data from 503 people with spinal cord injury has been analysed. Three quarters of the participants were male of an average age of 55 and have been living with spinal cord injury for a mean of around 20 years. The results show that social skills play an important role with respect to mental health and quality of life. However, they do not help to minimize limitations in everyday life. In more detail the study shows that people with a high expressivity and control report more social support, less depressive disorders and a higher quality of life. That means that people who are able to communicate to the people surrounding them how they feel and what they need in an appropriate way, receive more support, are mentally healthier and report a higher quality of life. Sensitivity, on the other hand, has a rather negative impact on the quality of life. People who are highly sensitive, through their empathy, also seem to perceive negative feelings and thoughts of others increasingly and this, again, has a negative effect on themselves. Social support, surprisingly, only seems to have a positive influence on limitations of everyday life, but does not contribute to quality of life and is not connected with depression. Possible implementation of the results A spinal cord injury has massive consequences on the life of the person affected, also when interacting with other people. This study shows that social skills are an important personal strength since more social support is connected with better mental health and a higher quality of life. Trainings to improve social skills during first rehabilitation may help the people affected to be better prepared for life in a wheelchair. Also outpatient psychotherapy clinics offer social competence trainings. Situations like the one described in the beginning of the text can be discussed in more detail during these trainings. The trainings mostly focus on learning how to be flexible and to avoid helplessness in different social situations that have changed through the dependency on the wheelchair. Social skills such as expressivity, sensitivity and control are being trained. Therefore it also increases the confidence in oneself to be able to handle the new situation while avoiding self-depreciation and withdrawal. Conclusion Saying how you are and feel, what you need, making friends and maintaining friendships and being socially active seems to be more important than the immediate support from other people. * fictitious names Reference: Paracontact 2/2013, Swiss Paraplegics Association updated: December 2013
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